COVID-19 has posed a considerable threat to all aspects of older Americans’ lives. The pandemic generated acute illness, emergency department (ED) visits, hospitalization, respiratory failure, and death. Pandemic-associated social isolation and loneliness further endangered older adults. Recovery from COVID-19 illness has commonly been followed by chronic symptoms, which may also precipitate ED visits. While vaccination has mitigated risks of serious illness requiring hospitalization, a booster dose is required to sustain protection. New treatments and therapies, including monoclonal antibodies and antiviral agents, have shown efficacy for older adults who are at risk of hospitalization. Older adults remain vulnerable in 2022, after two years of the COVID-19 pandemic. Emergency care for older patients is now challenged with health system staffing shortages and diminished access to care in community programs & skilled nursing facilities. This article attempts to synthesize the avalanche of discovery and innovation into a narrative review focused on the emergency and immediate post- ED care of the aging adult patients both during and as a result of the COVID-19 pandemic.

During the last two years of the COVID-19 pandemic, the emergency department (ED) has been the interface between our community and our health care system. As of March 13, 2022, over 79.5 million cases and 967,711 deaths have been attributed to COVID-19 in the United States (US).¹ This paper will provide key points about COVID-19 in older adults for emergency medicine providers, as exemplified in the case scenarios (Boxes 1 and 2). We will present a succinct review of COVID-19 epidemiology in older adults and review the presentation of both acute illness and the sequelae of COVID-19 illness. We will review reports of vaccination protection in older adults, ED treatment strategies, and the implications of COVID-19 on systems of care affecting older patients. Finally, we will describe the impact of the pandemic on the ED workforce.

Age is associated with severe COVID-19 outcomes. More than 54.1 million people are aged ≥ 65 years in the US. In 2020 these older persons suffered 81% of U.S. COVID-19 related deaths, and as of September 2021, their mortality was over 80 times greater than those aged 18-29 years.^2,3 Although residents in long-term care facilities made up < 1% of the U.S. population, those residents suffered 16% of all COVID-19 deaths.^4-8 Additionally, the COVID-19 mortality risk and disease severity associated with any high-risk condition increases with age.^9,10Lastly, older adults infected with COVID-19 were more likely than younger adults to require hospitalization, develop pulmonary failure, and need either noninvasive or invasive ventilation.¹¹

COVID-19 is a multi-organ disease and therefore causes a broad spectrum of signs and symptoms.¹² COVID-19 patients typically exhibit nonspecific symptoms of both upper and lower respiratory infection along with occasional nausea, vomiting, and diarrhea. One population screening study of 1,279 people demonstrated that fever, ageusia (loss of sense of taste), and weakness increased the odds of infection, while 36% of people testing positive were asymptomatic.¹³

In a Cochrane review of 44 studies, including 10 from the ED, only cough and fever had a sensitivity of at least 50% for COVID-19 illness.¹⁴ These studies used a positive RT-PCR as the reference standard, as well as clinical expertise and imaging. The presence of anosmia (loss of sense of smell) or ageusia had sensitivities below 50% but, specificities of 93%. However, the majority of signs and symptoms heralding potential COVID-19 infection had very poor diagnostic accuracy. Neither the presence nor absence of commonly attributed COVID-19 symptoms were accurate enough to be predicative or capable of excluding active illness. However, simple fever and cough may be useful to identify people for further testing, and the presence of anosmia or ageusia can serve as “red flags” for acute illness. There is a paucity of solid evidence for diagnosis of COVID-19 in older adults. COVID-19 signs and symptoms along with most serious infections in this population such as bacterial pneumonia, and urinary sepsis, all lead to non-specific presentations. The older adult’s presenting signs and symptoms can be used with diagnostic testing during the acute presentation in the ED. Notably, however, a negative RT-PCR test does not rule out COVID-19 and should not be used as the sole basis for treatment or management decisions. A false negative test could occur if testing was performed too early or too late to make an accurate diagnosis with the RT-PCR.¹⁵

The categorization of potential illness into actionable groups based on illness severity is more impactful to the emergency clinician.^16,17 Mild or moderate illness symptoms include fever, cough, aches, and lethargy without dyspnea at rest. Severe symptoms include dyspnea, tachypnea, and hypoxia, with features ranging from pneumonia to acute respiratory distress syndrome (ARDS), shock, or other organ dysfunctions. Kennedy and colleagues documented that delirium often existed without any other typical signs or symptoms of COVID-19 infection.¹⁸ Delirium was also associated with poor hospital outcomes and death. Delirium should therefore be considered as an indication for screening, testing, and evaluation for COVID-19 infection in older adults.

Descriptions of post-acute sequelae lasting beyond 12 weeks have been termed post-COVID-19 syndrome or long-haul COVID.19 Long-haul COVID incidence is predictably rising following high rates of omicron infection. Easy fatigability is the most common symptom of this COVID-19 complication. One study noted fatigability in 51% of those with long COVID findings. Anxiety, dyspnea, and headache were each noted in 38%.²⁰ Most studies followed a cohort of patients 60 days after their diagnosis, symptom onset, or hospitalization; or for 30 days after their recovery or hospital discharge. Studies typically use surveys imaging and/ or diagnostic clinical assessments outside of the ED.²¹ ED physicians and nurses should be aware that in some patients, symptoms may persist long after recovery from COVID-19. To make the diagnosis of long haul COVID-19 in older adults in the ED, the clinician would need to assess for a functional decline during the COVID-19 illness or find an acute illness that could explain the symptoms.

In one bit of favorable news for older adults, they are less likely than the younger cohort to experience post- COVID psychological distress such as PTSD, depression, and anxiety.²² Older adults generally exhibit higher levels of resilience to pandemic-related psychological stress.^23,24 In cognitively intact older adults, age may buffer COVID-19 related mental health deterioration.²⁵ Yet the harms of social isolation were not examined in these studies.

Older adults demonstrate higher rates of cognitive difficulties, persisting for months after discharge from COVID-19 hospitalization.²⁶ New onset dementia has been noted in about 2% of patients over age 65 in the first 14-90 days post- COVID-19 diagnosis.²⁷ This new dementia may cause increased ED presentations and require increased home supports to allow ED discharge. Enhanced access to cognitive screening from the ED should be considered for older adult COVID-19 survivors. Further research of long-haul COVID-19 will need to be integrated into ongoing research on ED dementia care.²⁸

The use of ethical principles such as maximizing benefit to the greatest number, preventing harm, and mitigating health inequities, may allow ED prioritization for access to new therapies with limited availability.²⁹ Shared decision-making in the ED is fundamental during the care of older adults.^30,31 ED providers have learned from pandemic resource shortages that the time to develop these strategies is before the next wave of illness outpaces resources.³²

The ED management of COVID-19, as with all illnesses, focuses first on stabilization of life threats. In COVID-19, the first and most important mainstay of treatment is supplemental oxygen. Supplemental oxygen can render patients eupneic, greatly reducing the potential for respiratory exhaustion.³³ Advanced age is associated with a high risk of pulmonary failure, need for mechanical ventilation, and death. Age ≥ 85 years, dyspnea, and polypharmacy are important predictors of mortality.³⁴ The amount of supplemental oxygen reaching the alveoli maximizes at a FiO2 of 44%, with flows in excess of 6L.³⁵ FiO2 can be increased to 100% when used with a 10 -15L/min flow rate.³⁶ Oxygen delivery may be further increased by high flow nasal cannula (HFNC) devices, which maintain FiO2 at 100% while increasing flow to as much as 60L/min.³⁷ The use of high-flow oxygen through a nasal cannula significantly decreased the need for mechanical ventilation support and time to clinical recovery compared with conventional low-flow oxygen use.^{41, 42}

If patients remain hypoxemic despite maximal therapy with HFNC, they are typically placed on higher levels of support such as CPAP or invasive mechanical ventilation (IMV). One study showed HFNC use effectively prevented IMV in 71.4% of patients.³⁸ Another study showed that one-third of hypoxic COVID-19 patients on HFNC did not require intubation.³⁹ Cochrane review determined that HFNC likely improves treatment compared to standard oxygen but makes little or no difference to treatment failure compared to NIV or NIPPV. Comfort is of particular importance in tolerating any therapy in cognitively impaired individuals. It is important that improvement in either short-term or long-term comfort with HFNC proved of very low certainty.⁴⁰ Among patients with severe COVID-19, HFNC seems to be an effective and safe treatment modality in acute respiratory failure.

Therapies for the treatment of COVID-19 are still in development with no effective curative therapy yet available. Table 1 describes COVID-19 treatment and resources for older adults.^{17, 64-70} Most of the guidelines and websites describe evidence-based care, without overtly defining older adult considerations. The Infectious Disease Society of America site,⁶⁵ and the WHO site,⁶⁸ note specific older adult considerations. The geriatrics portion of the American College of Emergency Physicians COVID-19 Management tool, 64 provides information from the early pandemic. The Society of Academic Emergency COVID Provider Toolkit, ¹⁷ provides succinct communication strategies, as well as interactive treatment recommendations. Finally, a side-by-side tool from the Health and Human Services is a clinician-friendly, graphic depiction of considerations for prescribing and administering treatments for those with mild to moderate COVID-19.⁷⁰

Monoclonal antibody (mAb) treatment is associated with decreased hospitalization and death in outpatients with mild to moderate COVID-19.^71-74 Older age is an indication for mAb treatments ⁷⁰ These treatments are especially important for ED providers discharging patients home with mild to moderate COVID-19 symptoms. We will not describe the mAb treatments which are not likely to be active against the omicron variant and limit our focus to sotrovimab.

•  Sotrovimab treatment has resulted in a 79- 85% reduction in hospitalization or death in high-risk adult outpatients compared to placebo.⁷⁵ This drug has activity against the Delta variant and is likely active in the Omicron variant.⁶⁸ Sotrovimab, similarly to the other mAb treatments, is authorized only for the treatment of lab-confirmed mild to moderate disease within ten days of symptom onset. See Table 2.
• Monoclonal antibody treatments are an effective treatment for those with laboratory-confirmed COVID-19 who are ≥ 65 years. Additionally, they may be used for younger patients at high risk of progressing to severe illness ⁷⁰ See important details that refer to eligible populations. These treatments are NOT authorized for hospitalized patients nor for those who require oxygen therapy. Recommendations for monoclonal antibody medication are often made at a regional/local level, based on the treatment that best covers local variants

Therapy with monoclonal antibodies changes rapidly subject to the latest available evidence and guidance of the Center for Disease Control. These therapeutics are distributed via the HHS Office of the Assistant Secretary for Preparedness and Response transitioned to a State and Territory-coordinated Distribution System for mAbs.⁷⁶

Social isolation and loneliness have been important health challenges for older adults during the COVID-19 pandemic.^{90, 91} Social isolation and loneliness are major risk factors linked with poor physical and mental health status. Mandates for stay at home and social distancing have exacerbated social isolation and loneliness. Economic insecurity, difficulty accessing health care services, and racial inequities compound the situation. Some innovative voice-controlled intelligent technologies have been implemented to counteract COVID- era loneliness.⁹² Emergency medicine physicians seldom recognize social isolation and its detrimental impact on the daily lives of vulnerable older adults.⁹³

Many older adults presenting to the ED may not have left home or had any interaction with a medical provider for weeks to months. The ED is often the site where family caregivers turn when they are unable to care for their loved ones. Efforts to identify medical problems are improved by an assessment of the individuals’ social supports and their access to community resources. Knowledge of these supports is critical for safe discharge in this population.

If the ED assessment shows that the patient does not require admission to the hospital, it is imperative providers understand the availability of current community resources. The pandemic has limited available usual resources, especially personnel. Typical orders for home care or other support services may not be available. A shortage of resources is a common theme. Community programs may be in short supply, including non-medical home care, transportation, community meal sites, behavioral health programs, in-person counseling, and aging services from the county to support family caregivers. Skilled home care agencies have, likewise, faced an increase in referrals with a lack of staff to provide the services. Table 3 shows how ED physicians can access community resources for older adults. Knowing and acting on what matters most to the older person honors the individual’s choices. ⁹⁴

The number of older adults in the U.S. living with dementia or related disorders has increased with continued rise projected in the coming decades.^{95, 96} Therefore, ED teams are increasingly more likely to evaluate and treat individuals living with dementia.⁹⁷

Individuals living with cognitive challenges often experience negative effects from busy ED environments. Loud noises, bright lights, overcrowding, and long waits to be seen, admitted, or discharged may all contribute to sensory overload and increased anxiety. In addition, building rapport quickly with unfamiliar providers may be difficult for individuals with mild, moderate, or advanced dementia.⁹⁸ These challenges have precipitated the need to improve dementia care in the ED and the evidence base on which to provide that care. GEAR 2.0 ADC provides recommendations for screening, communication, best care practices, and care transitions.²⁸

COVID-19, isolation, and limited social interactions have contributed to reduced physical activity, depression, and loneliness among older adults and care partners.^{99, 100} Limited physical activity and social isolation also contribute to accelerated cognitive decline. ¹⁰¹ As a result, family stress levels are heightened. Care partner capacity often influences whether or not a person living with dementia is taken to the ED or if they can return to their home or community safely.¹⁰²

The challenges of living with an older adult who is experiencing symptoms related to dementia have increased, and many care partners accompanying a person with dementia to the ED show signs and symptoms of weariness, anxiety, and exhaustion. In some cases, family or other care partners become ill themselves or are unable to find a paid caregiver due to the current staffing crisis.¹⁰³

Unfortunately, while many low or no-cost programs and services exist in most communities, ED staff members may not be aware of them, or may not have resources to make helpful referrals to support families.^{104, 105} An interprofessional team approach has been effective106 where social workers or care managers assist in providing information on community resources and follow up with primary care providers and/or dementia specialists. Reduced social worker or care manager hours in the ED limits patient or care partner access to the individuals on the team who are most familiar with community services such as Area Agencies on Aging (AAAs), senior centers, nutrition programs, home care agencies, and others. Table 3 provides online search tools for local community resources for older patients and their family caregivers.

Recruiting and retaining qualified staff, particularly clinical staff providing hands-on care, has been a challenge in nursing facilities and assisted living facilities for many years. High rates of staffing turnover in positions of nurses and nurse aides, are well documented and have been correlated with quality concerns, including citations related to infection control.¹⁰⁷ A recent article found that the average annual turnover rate for total nursing staff in these facilities was 128%.¹⁰⁸ Now, the situation is even more critical.¹⁰⁹ As in many healthcare settings, burnout has led to clinical staff leaving the front lines. In addition, nursing facilities are competing with hospitals and staffing agencies that are offering significant financial incentives. While most nursing facility staff have received the COVID-19 vaccine, some staff have left employment in certain facilities due to vaccine mandates. A small, 50-bed nursing home may only have four nurses on staff and if two are unvaccinated and choose to leave their jobs this can have a significant impact on that facility.

Inadequate staffing contributes to increased ED transfers. Staffing levels may also impact the ability of nursing facilities to receive patients from the ED or following a hospital stay.¹¹⁰ While the overall census of most nursing facilities is down, which would indicate a capacity for additional patients, short staffing forces some administrators to pause taking admissions. Patients who are COVID positive can be discharged to nursing facilities, and facilities often create dedicated COVID wings or sections. Depending on whether they have an active outbreak and ability to dedicate staff to the COVID unit, a given facility may decline to accept these transfers. This can lead to longer wait times for patients prior to discharge and have a ripple effect on ED and hospital bed capacity. Further, a patient who meets the criteria for nursing facility level care may refuse to transfer to the setting, which can also delay discharge planning.

Coordinating care at times of transition is a persistent challenge across the healthcare system. Table 4 provides a checklist of factors the ED should consider before transferring back to a long-term care facility. Older adults are particularly vulnerable to adverse events during such care transitions. These may include adverse drug events or medication errors, falls, abuse or neglect, pressure ulcers, and dehydration. The use of systematic approaches, such as checklists and warm handoffs, and calling the next site of care to ensure a coordinated transition, is even more essential.¹⁰¹

During the COVID-19 pandemic, frequently changing recommendations and requirements from the CDC, CMS, individual state departments of public health, and other agencies have created a particular challenge for the care of patients who are in acute distress, unstable, and require immediate, life-saving treatments.¹¹² Optimizing ED staff and patient safety under those conditions challenges our daily use of personal protective equipment (PPE), types and fit of masks, and frequency of staff testing. Additional issues are caused due to the availability of testing and treatment resources, vaccination and booster requirements, and other public health measures.

ED physicians and nurses, know that the last two years of serving on the frontline of an increasingly strained health care system has been exhausting. Our patients are sick, tired from long waits to be seen, and then are often boarding excessive amounts of time in the ED. It has been challenging if not impossible to care for them in the ways we want and which they deserve.

Our hospitals are strained to the breaking point and often unable to admit those requiring admission nor to support ED staff in managing patients to the extent needed. Many of the community resources we depend on for patient support have closed during COVID-19. We have been asked to keep visitors out of the ED, often causing confrontational conversations with patients’ loved ones. All the while we are worried about getting ill ourselves from a poorly understood or infecting our loved ones with a potentially deadly virus. There are no perfect answers but here are a few best practices shared by our ED colleagues from around the world.

The COVID-19 pandemic has greatly impacted ED care of older adults. Nonspecific symptoms and alterations of mental status are common presentations in both acute and long-haul COVID-19. Categorization into disease severity groups is useful for both treatment and disposition.

Supplemental oxygen is a mainstay of ED stabilization and applies equally to older persons. Vaccinations and boosters are lifesaving and reduce ED visits, especially in those most vulnerable. Strategies to maximize vaccination acceptance and ED distribution of vaccines in older adults should be implemented.

ED providers must have access to multiple external sources to help incorporate the constantly evolving treatments and recommendations, such as monoclonal antibodies and oral antivirals into ED practice. These treatments are particularly useful in the care of older adults with mild to moderate illnesses.

Psychosocial implications, care of those with dementia, and transitions to residential centers are subjects that must be understood by emergency providers in order to provide competent care and dispositions. The optimizing of professional functioning within the ED and maintaining both self-care and care of your colleagues are important for the day-to-day survival of emergency providers under pandemic-induced stress.

COVID-19, older adult, emergency department care, treatment